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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009958
Report Date: 04/21/2021
Date Signed: 04/22/2021 03:10:01 PM

Document Has Been Signed on 04/22/2021 03:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:CLOVERDALE EAGLETS PRESCHOOL & DAYCARE CENTERFACILITY NUMBER:
493009958
ADMINISTRATOR:BOEHM, JEANETTEFACILITY TYPE:
850
ADDRESS:530 NORTH CLOVERDALE BLVDTELEPHONE:
(707) 318-3951
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY: 30TOTAL ENROLLED CHILDREN: 0CENSUS: 23DATE:
04/21/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:18 PM
MET WITH:Jeanette BoehmTIME COMPLETED:
03:15 PM
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While Licensing Program Analyst (LPA) Amy Strother was conducting a remote Zoom Tele-Inspection visit with Licensee Jeanette Boehm (L1) in relation to another matter, the following observation was made during a tour of the facility. LPA Strother observed 7 toddlers preparing for nap in the toddler room. In the neighboring preschool room, 16 preschoolers were listening to a story read by Staff 1 at 12:20pm. At approximately 12:45pm, LPA Strother asked L1 about the preschoolers nap schedule. L1 stated that the preschool children do not want to nap and that their parents have been asked if they want their children to nap and all but 1 parent said no, so she does not set up mats for the preschool children. LPA informed L1 that regulation states that all preschool age children must be given the opportunity to nap or rest without distraction or disturbance from other activities at the center. LPA asked L1 what the daily schedule states as the nap/rest time. L1 went to the posted schedule on the wall and stated “12:30pm-2:30pm/3:00pm.” L1 then requested that Staff 1 (S1) and Staff (S2) set up nap/rest mats for all preschool children. LPA observed S1 and S2 had set up nap/rest mats for the preschool children.

LPA Strother requested proof of Mandated Reporter Training for all staff. At approximately 2:45pm, L1 stated that only she and one other staff, not present during today’s inspection, have completed the Mandated Reporter Training and have certificates on file. L1’s Mandated Reporter Training is on file with the Department. L1 was not able to produce a Mandated Reporter certificate for S1 or S2. L1 stated that Staff 3 (S3) had not yet worked at the facility for 30 days and will request that S3 submit her certificate prior to her 30th day of employment.
The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D

L1’s signature was not recorded on this Facility Evaluation Report (LIC809); however, L1 was provided with a copy of the LIC809; and L1’s confirmation of read receipt is on file.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/22/2021 03:10 PM - It Cannot Be Edited


Created By: Amy Strother On 04/22/2021 at 02:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CLOVERDALE EAGLETS PRESCHOOL & DAYCARE CENTER
FACILITY NUMBER: 493009958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2021
Section Cited
HSC
1596.8662(b)

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1596.8662 Availability of information regarding...reporting child abuse...proof of completion. (b)(1)On or before March 30, 2018,...licensed child care provider...shall complete the mandated reporter training...and shall complete...every two years...
This requirement is not met as evidenced by:
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L1 stated that she will ensure that S1 and S2 complete the Mandated Reporter Training over the weekend at website mandatedreporterca.com and send the certification of completion to LPA Strother at amy.strother@dss.ca.gov by 04/26/21.
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Based on interview, L1 did not have S1 and S2 complete their Mandated Reporter Training as required, which poses a potential Health, Safety or Personal Rights risk to the children in care.
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CCR


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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alexis Hollon
LICENSING EVALUATOR NAME:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2021


LIC809 (FAS) - (06/04)
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